By typing your name and submitting this form, you are agreeing to the above stated information. You are also confirming all of the information provided on this form is accurate to the best of your knowledge.

WAIVERS

Publicity Consent *

I authorize use of my or my child’s photograph on Chapel of Our Saviour’s website and usage for publicity purposes.
I do NOT consent the use of my child's photograph for publicity purposes

Medical Release *

MEDICAL RELEASE: In case of emergency, I/we, the parent(s) or
guardian(s) of the above-named participant, understand that every effort will
be made to contact me/us. In the event that I/we cannot be reached, I/we
hereby give permission to the physician(s) and/or dentist(s) selected by the
Chapel of Our Saviour staff to hospitalize and secure proper treatment,
including tests, x-rays, anesthesia, and/or surgery, for the participant.

Liability Waiver *

The undersigned parent(s) or guardian(s) and the undersigned participant hereby represent that the
participant is the child or ward of the parent(s) or guardian(s). The parent(s) or guardian(s) and the
participant understand that this program may involve travel in mixed groups and riding in private vehicles
utilizing available local accommodations for travel, meals, and lodging. It is understood that Chapel of
Our Saviour will employ only the usual and locally acceptable standards of instruction, travel, meals,
lodging, and medical services. Adult members of the staff will determine the day-to-day operations of the
program as they deem appropriate. Chapel of Our Saviour has a history of successful operations, but
Chapel of Our Saviour is not an insurer of the health, well-being, safety, or morals of any participant and
cannot guarantee every participant will achieve the education or obtain the enjoyment anticipated from
the program.
It is understood that the program may be hindered disrupted, or rendered impossible by: changes,
irregularities, or failure in transportation services, lodging accommodation, and food services; strikes,
mischief, terrorist acts, or war; lack of cooperation or sickness of one or several of the participants;
governmental restrictions and regulations; and weather or other acts of God. The parent(s) or guardian(s)
and participant accept these hazards as those which may accompany these types of activities.
Parent(s) or guardian(s) and participant represent to Chapel of Our Saviour that the participant is in good
physical and emotional health and is a person who is likely to give the required cooperation toward the
success of the program and that the participant is not likely to interfere unreasonably with the rights of
other participants or those in charge of the program. In the event that Chapel of Our Saviour should
determine that the physical or emotional health of a participant is such that further participation by
him/her would endanger his/her health or welfare or the health or welfare of other participants or if
Chapel of Our Saviour should determine that a participant behaves in a manner detrimental to the best
interest of the program or other participants, Chapel of Our Saviour may expel such a participant from the
program. The parent(s) or guardian(s) and participant agree to pay the costs of returning the participant to
his/her home and hereby release Chapel of Our Saviour from any liability arising out of such expulsion
and agree that no refund of the program fee will be allowed.
CANCELLATIONS: Cancellation by a participant or his/her family will result in the forfeiture of any
money actually spent or committed on behalf of the participant up to the date of cancellation.
CHANGES: This program has been designed long before departure. Chapel of Our Saviour reserves the
right to amend any program for operational reasons and/or in the best interest of the participants’ safety
and convenience. Chapel of Our Saviour reserves the right to cancel the program prior to departure. In the
event Chapel of Our Saviour cancels, Chapel of Our Saviour shall refund all monies received for the
canceled program. In any case, Chapel of Our Saviour shall have no other liability to the participants.
RIDING IN PRIVATE VEHICLES: It is understood by the parent(s) or guardian(s) and participant that
transportation for this program will be primarily in private vehicles driven by the youth ministry
volunteers and staff. It is understood that every effort will be made to have more than one adult in each
vehicle; however, if the youth staff deems it appropriate, exceptions may be made to this policy for this
program. The parent(s) or guardian(s) hereby give permission for the participant to ride in private vehicles
with only one adult and agree to release and hold harmless Chapel of Our Saviour from any claims or
demands, for injuries or damages arising out of the enacting of the above-stated policy and its exceptions.
MEDICAL RELEASE: In case of emergency, the parent(s) or guardian(s) understand that every effort
will be made to contact them. In the event that they cannot be reached, they hereby give permission to the
physician(s) or dentist(s) selected by the Chapel of Our Saviour’s staff to hospitalize and secure proper
treatment, including tests, x-rays, anesthesia, and/or surgery, for the participant.
RELEASE: The parent(s) or guardian(s) and participant hereby release Chapel of Our Saviour from any
and all claims or demands, for injuries or damages arising out of the acts or omissions of the independent
contractors employed by Chapel of Our Saviour, such as theme parks, ski resorts, restaurants, places of
lodging, doctors, and dentists; the acts or omissions of other participants or strangers; the acts or
omissions of Chapel of Our Saviour performed or omitted in good faith and in a manner reasonably
believed by them to be within the scope of authority granted to them by this agreement and in the best
interest of the majority of the participants in the program, unless they are guilty of gross negligence or
willful or wanton misconduct.
PHOTOGRAPHS: Any photograph or audio or video recording of the participant or comments or
statements made by the participant may be used in future materials by Chapel of Our Saviour and/or
posted on the Chapel of Our Saviour website.
INDEMNIFICATION: In the event the participant is a minor at the time of execution of this agreement,
the parent(s) or guardian(s) of the participant hereby agree to indemnify and hold harmless Chapel of Our
Saviour from any claim covered by this agreement, which may be brought by or on behalf of the
participant, or by or on behalf of a parent or guardian of a participant, and they hereby agree to reimburse
Chapel of Our Saviour for any and all expenses that may be incurred in connection with the assertion of
such claim, by or on behalf of a participant or a parent or guardian, including court costs and reasonable
attorney’s fees.
CONSENT: The parent(s) or guardian(s) hereby give their permission and consent for the participant to
participate in the program.
The undersigned agree that upon admission of the participant into the program, they will be bound by the
terms of this Release and Agreement. The undersigned acknowledge that they have read and understand
the terms of the Release and Agreement. This Release and Agreement supersedes and nullifies any
previous agreement, implied or expressed, made between Chapel of Our Saviour and the undersigned for
this program.

FORM SUBMISSION

By submitting this form, you (parent/guardian) agree that all information provided is accurate to the best of your knowledge. You agree and consent to the medical and liability waivers as stated above.